Anderson v. Unum Life Ins. Co. of America

• Decision Date: 13 February 2006
• Docket Number: No. 2:01 CV 894 D.,2:01 CV 894 D.
• Citation: 414 F.Supp.2d 1079
• Parties: Donya Leigh ANDERSON, Plaintiff, v. UNUM LIFE INS. CO. OF AMERICA, d/b/a UNUM Provident Corp., Defendant.
• Court: U.S. District Court — Middle District of Alabama

414 F.Supp.2d 1079

Donya Leigh ANDERSON, Plaintiff, v. UNUM LIFE INS. CO. OF AMERICA, d/b/a UNUM Provident Corp., Defendant.

No. 2:01 CV 894 D.

United States District Court, M.D. Alabama, Northern Division.

February 13, 2006.

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COPYRIGHT MATERIAL OMITTED

M. Clayborn Williams, Thomas O. Sinclair, Jonathan H. Waller, Campbell Waller & Poer LLC, Birmingham, AL, for Plaintiff.

Stephen R. Geisler, Kristen S. Cross, Christopher A. Bottcher, Kaye K. Houser, James S. Williams, Sirote & Permutt, P.C., Birmingham, AL, for Defendant.

MEMORANDUM OPINION AND ORDER

DE MENT, Senior District Judge.

I. INTRODUCTION

Plaintiff Donya Leigh Anderson ("Anderson") brings this lawsuit against UNUM Life. Insurance Company of America ("Unum"), challenging Unum's decision to deny Anderson's claim for long-term disability benefits under a group policy offered by her employer, Shaw Industries, Inc. ("Shaw Industries"). This cause arises under the. Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §§ 1001-1461, and, specifically, is a claim for benefits pursuant to 29 U.S.C. § 1132(a)(1)(B). The parties have stipulated that the merits of this case may be submitted and tried on the written record, although there are disputes as to the applicable standard of review and the scope of the record for review. (Order (Doc. No. 89)); (see also Order (Doc. No. 87).)

Anderson and Unum have submitted briefs and evidentiary submissions in support of their respective and opposing positions. (See Anderson Br. & exhibits attached thereto (Doc. No. 90); Unum Br. & Exhibits attached thereto (Doc. No. 93)); (see also Anderson Reply (Doc. No. 94).) The court carefully has considered the arguments of counsel, the relevant evidence and the applicable law and, for the reasons set forth herein, finds as follows: (1) The delegation of authority by Unum to Unum-Provident to decide Anderson's claim for benefits was not authorized by the policy, thus, necessitating de novo review; (2) the de novo standard of review permits consideration of evidence which was not before the claims administrator at the time the decision to deny Anderson's claim was made; and (3) Anderson is entitled to benefits under the policy in the amount of $6099.97, plus prejudgment interest.¹

II. JURISDICTION AND VENUE

The court exercises jurisdiction over this removed ERISA action pursuant to 28 U.S.C. 1441(a) and 29 U.S.C. 1132(a)(1)(B). See Lazorko v. Pennsylvania Hosp., 237 F.3d 242, 247 (3rd Cir. 2000). Venue is proper in the Middle District of Alabama pursuant to 29 U.S.C. 1132(e)(2) and 28 U.S.C. § 1391.

III. BACKGROUND

A. Procedural History

Anderson purchased a long-term disability insurance policy from Unum which was made available to her through her employer, Shaw Industries. Unum's denial of Anderson's request for long-term disability benefits prompted Anderson to sue Unum. Anderson originally filed this lawsuit in state court, alleging state law claims, but Unum removed the action here based on federal question jurisdiction arising from ERISA's preemptive effect or, alternatively, based on the presence of diversity jurisdiction. See 28 U.S.C. §§ 1331, 1332, 1441. Unum contended, in part, that Anderson's claims, properly pleaded, were ERISA claims because the policy at issue was an "employee welfare benefit plan" within the meaning of 29 U.S.C. § 1002(1).

In an opinion previously entered in this case, the court agreed with Unum and dismissed Anderson's state law claims, but permitted Anderson to file an amended complaint to state an ERISA claim. Although first disallowing an interlocutory appeal (see Orders (Doc. Nos. 41, 44)), the court granted Anderson's motion for reconsideration and permitted Anderson to appeal the court's ruling on the issue of ERISA preemption. (See Doc. Nos. 57, 80.) The Eleventh Circuit affirmed. See Anderson v. UNUM Provident Corp., 369 F.3d 1257 (11th Cir.2004). The policy at issue in this case, therefore, is governed by ERISA.²

Subsequently, Unum filed a motion for an order that the case be tried on the briefs and asserted that, under an arbitrary and capricious standard of review, the court is limited to examining the administrative record. (See Unum Mot. for Order Requiring Case to Be Tried on Briefs at 2, ¶ 3 & n. 1 (Doc. No. 55).) Anderson initially opposed Unum's motion (see Doc. No. 67), but later agreed with Unum to the extent that she conceded that the court may resolve this case based upon the written submissions. (Doc. No. 87.) Anderson, however, advances the position that de novo review applies to her ERISA claim for benefits and that the court may consider evidence outside of the administrative record.

B. The Policy

In 1990, Anderson began employment as a full-time hourly employee with Shaw Industries, the "largest carpet manufacturer in the world." Anderson, 369 F.3d at 1259; (Anderson Aff. ¶ 3 (Ex. to Doc. No. 90).) By virtue of her employment with Shaw Industries, Anderson was covered by a group long-term disability insurance policy issued by Unum, Policy Number 550054 (hereinafter "the policy"). All long-term disability benefits under the policy are paid by Unum. See Anderson, 369 F.3d at 1266.

The policy refers to Unum Life Insurance Company of America as "Unum." (See UPCL00071 (Ex. to Doc. No. 93).) The Certificate Section of the policy states: "When making a benefit determination under the policy Unum has discretionary authority to determine your eligibility for benefits and to interpret the terms and provisions of the policy." (UPCL00061 (Ex. to Doc. No. 93).) A complete copy of the policy is part of the record, see, supra, footnote 2. (See Ex. to Doc. No. 93.)

The policy provides that whether an insured is "disabled" is a determination made by Unum and defines "disabled" as follows:

— You are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury;

— You have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury; and

— during the elimination period, you are unable to perform any of the material and substantial duties of your regular occupation.

(UPCL00057 (emphasis in original) (Ex. to Doc. No. 93).)

The policy embodies a "glossary" of terms. The policy defines "limited" as "what you cannot or are unable to do," (see UPCL0039 (Ex. to Doc. No. 93)), and "material and substantial duties" as those "duties that ... are normally required for the performance of your regular occupation; and cannot be reasonably omitted or modified." (See UPCL00039 (Ex. to Doc. No. 93).) "Regular occupation" is defined as "the occupation you are routinely performing when your disability begins." (See UPCL00038 (Ex. to Doc. No. 93).) "Sickness" includes "an illness or disease" which commences while the insured is covered under the policy. (See UPCL00037 (Ex. to Doc. No. 93).) "Elimination period" is defined as "a period of continuous disability which must be satisfied before you are eligible to receive benefits from Unum." (See UPCL00040 (Ex. to Doc. No. 93).) The elimination period under the terms of the policy is 90 days. ("Benefits at a Glance," UPCL00069 (Ex. to Doc. No. 93).)

Anderson's Long — Term Disability Claim

Anderson worked full-time as a "color sampler" for Shaw Industries and, at all times relevant to this lawsuit, was insured under the policy at issue.³ In March 2000, Anderson learned that she was pregnant. After March 23, 2000, Anderson did not return to her job at Shaw Industries. On March 29, 2000, at approximately six to seven weeks gestation, Anderson sought treatment from her obstetrician, Dr. Kathy Payne ("Dr. Payne"), who on that date ascertained that Anderson was "disabled" due to pregnancy-related symptoms. (Attending Physician Statement (UPCL00003) (Ex. to Doc. No. 90)); (Dr. Payne Dep. at 22-23 (Ex. to Doc. No. 90)); ("Prenatal Record," UPCL00008 (Ex. to Doc. No. 90).) Anderson initially received weekly short-term disability payments in the amount of $175.00 for 13 consecutive weeks.⁴ (See UPCL0005-UPCL00006 (Ex. to Doc. No. 90)); (Anderson Dep. at 48 (Ex. to Doc. No. 93).)

On or about May 26, 2000, Anderson submitted a long-term disability claim under the policy. The preprinted claim form provided that the form must be completed by the claimant, the employer and the attending physician and that "[i]ncomplete or illegible answers may result in delay of payment consideration." (Anderson's claim form (UPCL00002 — UPCL00007) (Ex. to Doc. No. 90).)

On her claim form, Anderson identified her disabling sickness as "pregnancy." In response to the question asking the date she was "first treated for this condition," Anderson answered, "March 29, 2000." (UPCL00005 (Ex. to Doc. No. 90).) She indicated that she began receiving treatment on that date from Dr. Payne. Anderson noted, and Shaw Industries confirmed in its portion of the claim form, that Anderson's last day of work was March 23, 2000. (Id.); (UPCL00006 (Ex. to Doc. No. 90).) Shaw Industries also provided that, during Anderson's last two-week schedule, she worked a three-day, 36-hour shift for one week, followed by a four-day, 48-hour shift the next week. (UPCL00006 (Ex. to Doc. No. 90).)

On her claim form, Anderson described her job duties as a "color sampler" as follows: "lifting 50 lb. packages to combine buggies, pushing and arranging 1,000 lb. buggies, stretching, bending and squatting to lace and doff color check machines." (UPCL00005 (Ex. to Doc. No. 90).) She indicated that, on a weekly basis, she devoted 30 hours combined to these physical tasks, but that her "pregnancy" restricted her from continuing to perform these duties. (Id.)

Shaw Industries also completed a "job analysis" form as part of Anderson's claim package. (UPCL00002 (Ex. to Doc. No. 90).) Shaw Industries provided that Anderson's work required considerable standing and walking on a concrete surface and that her job required lifting and carrying packages...